GuidelinesSummary for General Practitioners
Chronic ConditionSelf-Management
The Royal Australian College of
General Practitioners
Section 1 Introduction
Section 2 Problem definition
Section 3 Planning (Goals)
Section 4 Management strategies
Section 5 Monitoring
Section 6 Organisation of the practice
Section 7 Underlying theories
Section 8 Evidence levels
Designed for use with practical guide & desktop guide
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Designed for use with practical guide & desktop guide
Guideline for General PractitionersWorking with Chronic Conditions
Chronic ConditionSelf-management
Contents
Section 1 Introduction 3
Section 2 Problem definition 4
Section 3 Planning (Goals) 7
Section 4 Management strategies 9
Section 5 Monitoring 11
Section 6 Organisation of the practice 13
Section 7 Underlying theories 15
Section 8 Evidence levels 21
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Improving health outcomes for Quality of Strength of people with chronic disease by: evidence Recommendation
Promoting and encouraging self-management II A
Reducing life style risk factors of obesity, I A
physical inactivity and smoking
Defining problems, setting goals and III B
developing plans through a collaborative
approach between providers and the patient
Regular follow up at timed intervals III B
to monitor health status
Educational programs directed at patient to II B
improve knowledge relating to the condition
Targeting interventions using the Stages III B
of Change approach
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Section 1 - Introduction
The purpose of this guideline is to assist GPs in facilitating self-management in patients with
a chronic condition by providing a framework for effective interactions and management
strategies. A chronic condition is one that presents itself for longer than six months, and that
has slow changes. self-management concerns patients being responsible for managing
some aspects of the condition themselves in partnership with their GP.
• self-management has been shown to improve quality of life as well as reducing
hospitalisations and visits to health care providers 1 (Lorig et al 1993)
• self-management requires a patient-centred approach that is generic in nature,
rather than condition-focussed
• The 'stages of change' model, together with a patient-centred approach and
informed decision-making can be used as a framework upon which theory about
self-management can be built
It is always important to listen to patients' ideas and feelings about their illness, but this is
especially true when the patient has a chronic or longstanding condition. Because patients
live with the illness on a daily basis over a long period of time, their ideas, thoughts and
behaviours will have an impact on how successfully they and their GP are able to work
together to manage it.
Greater time may be required during the consultation to discuss such issues with patients,
and in turn to develop an effective treatment plan with them. With the limitations of the
current fee for service system, the use of the Enhanced Primary Care (EPC) Medicare Benefit
Schedule (MBS) items, specifically community care planning and case conferencing, may
complement strategies for chronic condition self-management. The principles outlined in
this summary do not need to be completed in their entirety in one consultation, but rather
as a process over time.
When treatment is jointly planned and negotiated, and information is shared between
doctor and patient, the patient is assisted to exercise autonomy and follow an agreed plan.
Chronic condition self-management
involves the person with the chronic disease engaging in activities that protect and
promote health, monitoring and managing of symptoms and signs of illness, managing
the impacts of illness on functioning, emotions and interpersonal relationships and
adhering to treatment regimes. 2 p 1 (Centre for Advancement in Health 1996: p.1).
Due to the geographical and cultural diversity of Australia, these guidelines will require
modification and adaptation by local primary care providers to reflect their community's unique
needs. 3
Intr
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Relapse Not thinking about change
Thinking of change
Ready for changeChanging cehaviour
Maintaining
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ion Section 2 - Problem Definition
Chronic condition self-management becomes possible, when the GP and patient work
together. Clear definitions of what the patient sees as problems are required. This ensures
that the areas identified for action are those that are significant to the patient and his or her
lifestyle. This process may be initiated by providing the patient with, and discussing, a self-
management information pamphlet.
Assessment begins with a definition of needs andacknowledgment of strengths
1. Identify the impact of illness (FIFE) Determine patients’ illness experience:
• Feelings: anger, fear, guilt, or relief
• Ideas: about disease and the meaning of illness to the person
• Effect on Function: daily activities, family relationships, requirement of lifestyle change
• Expectations: patients' expectations of the GP ie action or just listen
2. Identify the specific symptoms and signs of illness
• With the patient, identify the target symptoms of the existing illness, eg pain, SOB
• Use objective measures for assessment if possible, e.g. pain scales
3. Identify factors leading to the preservation and promotion of health (lifestyle)
• Consider factors that may be related to and affect the presentation and subsequent
course of the illness ie diet/nutrition, weight, smoking, stress and exercise
• Use specific guidelines relating to these lifestyle conditions (see the Guidelines for
Preventative Activities in General Practice – The Red Book 3) [RACGP 2001]
• Determine which stage of change the patient is at by asking "How do you feel about
your _____ (e.g. weight)?" 4 (Richmond et al 1998)
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Determine strengths of and barriers to the capacityto self manage
Patients’ self-management skills need to be identified to determine their ability to self-
manage. This is performed alongside previous assessments rather than in isolation, and the
information may be obtained over a series of visits.
Practical points
to consider
What stage of change is the
patient in?
Is the patient concerned
about lifestyle behaviours?
Does the patient recognise
the benefits that may come
with change?
Does the patient want
information related to the
illness?
Does the patient have a
symptom action plan?
Is there a need to consider
the management capacity of
carers and others in the
immediate social
environment as well?
Factors
affecting self-
management
Motivation
Knowledge of
condition
Knowledge of
symptom
management
plan
Key aspects relating to the patient’s ability to take on a self-management role
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How can these factors
be modified
This will be affected by the
stage of change that the
patient is currently
experiencing.
It is generally accepted that
programs that seek to
improve health by increasing
patient knowledge alone are
rarely successful. It does help
the patient, though, in the
process of decision-making.
Information on managing a
crisis or emergency is
important eg what should
the patient or carers do?
The management capacity
of carers and others in the
immediate social
environment should be
considered.
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Practical points
to consider
Are there sensory or
cognitive impairments that
may affect the patient’s
ability to self-manage?
What effect do religious,
cultural and family beliefs
have on the patient’s
thoughts about self-
management?
Is the patient confident in his
or her ability to self-manage?
Does the patient feel that he
or she has the skills to make
changes and control the
illness?
What aspects of life ie family,
friends, literacy, access,
employment, culture need to
be considered?
How can these factors
be modified
Consideration of other
conditions that may affect
self-management such as
sensory or cognitive
impairments (eg hearing or
visual loss, dementia).
Understanding the religious,
cultural and familial beliefs
that may influence the effect
of management
interventions.
The extent of the patients’
confidence in their capacity
to self-manage, the extent to
which patients value
themselves and extent to
which they feel they have
some control over their ability
and desire to assume a self-
management role.
Consideration of such things
as access to services and
cultural aspects of the
patient’s life.
Factors
affecting self-
management
Co-morbidities
Health beliefs
Self-efficacy
Social context
Key aspects relating to the patient’s ability to take on a self-management role
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There are currently no validated tools available to assess capacity for self-management, and the
need for a formalised assessment is not widely acknowledged in the literature related to chronic
condition self-management. An assessment tool is being developed in Australia to assist the
practitioner in identifying areas that may require intervention to improve self-management
behaviours. Refer to section3.7 in the theory and evidence overview.
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Section 3 - Planning (Goals)
A patient centred approach must be used for management to be truly shared. This
enhances self efficacy (patients’ confidence in their ability), encourages greater
responsibility and fosters a partnership approach between the GP and patient. A plan that
incorporates patient preferences has the best chance of resulting in concordance and thus
improved quality of life for the patient.
In the case of patients who may be unable to fully participate in the planning process due
to dementia or reduced cognitive abilities, family and caregivers need to be involved to
increase the likelihood that patient preferences are included. This becomes 'family focussed
medicine' rather than 'patient centred medicine'. It may also be used at times when the
assistance of the whole family or social environment is needed to help bring about
motivation and change.5 (Fisher and Weihs 2000)
Goals should be determined as specific objectives, and these objectives should be SMART:
• Specific
• Measurable
• Achievable
• Realistic
• Timely
This enables easier monitoring of the plan and also provides a useful tool for motivation.
It is essential that the goals are understood and agreed to by the patient. Initiating too
many changes at once may result in poor concordance and the patient may become
discouraged.6 (Von Korff et al 1997)
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1. Determine specific goals according to the problems and in line with the capacity of the
patient to self manage. These goals can be categorised as:
• Increased knowledge concerning the illness, lifestyle factors and treatment options
• Reduced symptoms relating to the illness
• Use of symptom action plan and diaries
• Concordance with medication and other management strategies
• Reduction in lifestyle risk factors
• Improved function
• Reduced impact on social, emotional and personal life
2. Prioritise goals in collaboration with the patient. Patient preferences are central but are
influenced by the capacity for self-management and the resources that are available.
3. Determine outcomes for each of the goals using the SMART principles.
4. Decide on time frame and responsibility for achievement of goals and/or monitoring.
Where multiple health professionals are involved it is necessary to clearly identify the
roles and responsibilities of each person. The control of this process must rest with the
patient. This will also include the means of monitoring progress including frequency of
review (see Monitoring section).
5. Select appropriate interventions to achieve goals using the decision making principles
outlined earlier.
6. Document the plan. The plan should be documented in the patient's notes and a copy
given to the patient. An example of incorporating the process into a care plan format,
along with standards for care planning, are contained in the practical guide. The
patient's consent for treatment should also be documented as part of the plan.
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Section 4 - Management Strategies
Choose the most appropriate mix of strategies for Chronic Condition Self-Management
depending on the goals, availability of resources, quality of resources and patient self-
management skills.
Successful self-management interventions for people withchronic conditions should include:
1. A focus on the patient's perceived needs
2. Practise and feedback in new skills, including decision-making and problem-solving
3. Attention to emotional and social management in addition to medical management
4. Use of techniques to increase patients' confidence in their ability to manage
their conditions
5. Emphasis on the patient being active in the GP/patient relationship
Categories of Intervention
• Education and information (consumer guides and handbooks) - provide each person
with information about the illness.
• Motivational interviewing - involves patients examining the pros and cons of change
with the assistance of the GP and then making the decisions for themselves.
• Peer support and motivation - groups that exist within the community for common
interests such as weight loss and fitness, eg community walking groups.
• Structured condition specific programs - groups and programs that are run by
organisations such as Asthma Foundation and Arthritis Foundation.
• Self-management programs led by lay people - where they teach techniques for
illness management (such as relaxation and stress management), provide inspiration from
role models and offer mutual support.
• Symptom diaries - used to help patients monitor their illness and generate information
that can be used in the management plan.
• Community based skill groups - groups that exist to enhance skills for healthy lifestyles
such as fitness, nutrition (food purchasing and cooking) and life skills.
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• Referral to another health provider - the expertise of another health provider may be
required to enhance another area of self-management performance eg chronic pain
management, medication review, stress management or ADL adaptation for
independence. This may be done utilising the Care Plan and Case Conference items of the
EPC Package (see Appendix 2 of the practical guide).
To assist patients to be effective in managing their owncondition, a range of management options may be used to:
• Develop self-management skills
• Medication use
• Pain control
• Adjustment to change
• Coping with emotional reactions
• Guide behaviour change related to lifestyle and activities
• Develop knowledge
• Monitor changes in disease and symptoms
• Provide social support
• Effective use of community resources
It is important to understand that a strategy that is successful for one person may not be for
another, for example, group programs, condition specific literature or a symptom diary have
varying effects depending on the person.These self-management components can be used
to improve a person's management of the condition by putting the patient at the centre
around which treatments are built.
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Section 5 - Monitoring
Why monitor?
Monitoring the effect of a chosen intervention is important for several reasons:
• Enables a mechanism to determine the effectiveness of interventions
• Provides information that can be used to motivate patients to continue with the
intervention
• Provides an opportunity to review progress and adjust the management plan if necessary
How the outcomes are to be measured needs to be determined prior to commencing the
intervention. Ideally this should occur at the planning stage when the goals are decided
upon. Furthermore it is essential that the way in which they are measured is determined
jointly with the patient, and the parameters for success or failure are agreed upon and
documented.
Selecting the measures
The selection of what outcomes to measure often relates directly to the selected goal.These
indices should be valid and reliable as well as easy to measure and easily understood.
The selection of the indices can be broadly categorised into three main groups:
1. Physiologic measures. This may relate to illness specific disease markers and are
best used for goals reflecting aspects of illness or lifestyle. Examples include blood
sugar levels, blood pressure, PEFR and weight. They are things that can be measured
by the patient at home, or specific biological markers that can be measured at
appropriate intervals such as Hb A1c, cholesterol and LFTs.
2. Clinical measures. Judgements made by the doctor and patient concerning overall
progress. As it involves a degree of judgement these are not as precise as the
objective measures but rely on an overall assessment of the condition. A systematic
approach can be taken by using a scaling system to grade this.
3. Quality of life measures. Can be used to measure functional improvements. Patient
assessment is central in this measurement and various validated instruments or
simpler scales can be used depending on the goal. They are best used for goals
involving symptom control (eg pain) and functional improvement (mobility).
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When to measure
Deciding how often to measure should also occur at the planning stage. The monitoring
intervals will depend on what is being measured and how quickly change is wanted or
required. Evidence based principles should be used when deciding on monitoring time
while still keeping in mind individual circumstance. This is particularly relevant for disease-
specific objective indices.
How to measure
Measurement and review can take many different forms and shouldn't be confined to a
clinical visit with the doctor. These can include:
• Regular visits to the GP
• Regular visits to the nurse at the practice
• Phone contact initiated by the GP or the patient
• Laboratory investigations
• Electronic reviews (through email)
• Letter/postcard contact
Refer to Section 6 on Organisation of the Practice for ways that monitoring methods can be
developed and enhanced.
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Section 6 - Organisation of the Practice
The following provides suggestions for ways in which a general practice setting can be
organised to promote the facilitation of self-management for patients with chronic
conditions. A review of the structure within which the GP operates will enable the guideline
to be put into practice more easily eg scheduling longer appointments to determine the
needs and develop a management plan with a patient.
1. Practice staff -with training and an increased awareness of the unique needs of those
with chronic conditions, practice staff can assist with the following:
• Booking longer appointment times
• Booking appointments with both the GP and Practice Nurse when required
• Operating an effective recall system
• Knowing where the appropriate forms and information are when needed eg Health
Assessment, Care Plans, disease specific literature
• Keeping up to date contact details of other health care providers in the area in the
Practice Manual. This may also be coordinated through the local Division of General
Practice
• Assisting in the organisation of a case conference or care plan
• Maintaining current information regarding MBS items that can be used for longer
consultations, care planning and case conferencing
• Using Carelink as a central source of information for agencies providing community
care and support
2. Practice nurse/s - depending on the individual skills and training levels of the practice
nurse, they can provide a complimentary role within the practice in the following areas:
• Assist with screening and population health activities
• Assist with the information collection component and/or the environmental
assessment for the health assessment in the elderly
• Assist with the organisational and liaison components of care planning and case
conferencing
• Provide disease specific education and lifestyle counselling if appropriately
informed/educated
• Ensure educational resources are up to date
• Using Carelink as a central source of information for agencies providing community
care and support
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3. Other health Care Providers - as patients with chronic conditions are more likely to
require multidisciplinary care, it is important to develop two way communication with
other health providers in the area. This may be done either formally or informally and
will assist with the development of care plans if required.
4. Information technology - effective patient identification (for risk factors) and recall is
made easier using an appropriate IT based system. This enables systems to be
maintained for the care and monitoring of those with chronic conditions.
5. Screening and recall systems - the recent SNAP framework (Department of Health
and Aged Care 2001), which is a systems approach to managing the risk factors of
smoking, nutrition, alcohol and physical activity, identifies that targeting common risk
factors within a primary care setting can impact on a number of chronic conditions.
Strategies to implement these initiatives within general practice are most effective
when there are systems in place to provide both health promotion and primary and
secondary prevention screening. The RACGP "Putting Prevention into Practice: a Guide
for the Implementation of Prevention in the General Practice Setting (The Green Book)"
(RACGP 1998) provides an excellent overview and guidance on these approaches.
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sSection 7 - Underlying theories
The nature of illness is changing as the world's population is aging. A growth in age as well
as improvements in health and treatment of medical conditions, have resulted in a greater
number of people living with chronic conditions. The implication of this on health service
delivery, patient care and health resources is vast, increasing the importance of introducing
and sustaining new methods in the management of health care. One method for enhancing
chronic condition management is the expansion of self-management.
Patients’ attitudes to health and knowledge of their condition are significant factors in
understanding their health-related behaviours. Following is a brief summary of theories that
relate to the way in which patients may present to their GP, and the rationale for the way
they approach and adopt self-management.
The importance of following treatment
Not all patients follow their treatment even if it has been set up to meet their needs and
wants. This should not be seen as a difficult behaviour, but rather that person's decision. A
patient's wish to follow treatment can be seen as whether the benefits of changing a
behaviour (eg taking medication properly or taking exercise) is greater than the costs of not
doing these things. A patient's decision not to follow treatment should be seen as part of his
or her freedom to make a choice about management. (Centre for Advancement in Health
1996). It might not be seen as the correct choice, but it is the patient's right.
This does not always happen on an all or nothing basis as a patient may choose to stay with
certain parts of management over others. Three different types of behaviour have been
categorised where patients may not follow what the health provider wants them to do
(Thorne 1990):
• Changing the treatment plan without talking with the health provider
• Choosing certain parts of the treatment plan to follow
• Agreeing to treatment suggestions without actually meaning it
It is important to know what patients think about their health and to consider this when
planning treatment. To explain how these thoughts turn into health behaviours there are
behaviour theories such as the Health Belief Model (Rosenstock 1974), and the Stages of
Change theory (Prochjaska et al 1992).
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Theories of Health Behaviour
1. Benefits of Health Behaviour (Health Belief Model)
Patients weigh up the perceived benefits and costs when deciding on their ability to carry
out a behaviour (Rosenstock 1974). These benefits and costs include:
• perceived susceptibility to the problem
• perceived severity of the possible consequences
• perceived benefits of specific actions
• perceived barriers to taking action
The perceived threat or the expectation of outcome of adopting or changing a behaviour
relates directly to patients’ self efficacy, or their perceived ability to carry out the action.
2. Stages of Change
Health interventions should be timed to coincide with a patient's cognitive behavioural
stage. The Transtheoretical Model (Procheska et al 1992) identifies five basic stages of
change, which are viewed as a sequential, ongoing process. During this process of change,
the patient may have differing levels of motivation or readiness to change and may repeat
a stage or relapse (Cassidy 1999). Each time a stage is repeated, the person learns from the
experience and gains skills to help move on to the next stage.
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Pre-contemplation
(Not thinking of
cvhange)
Contemplation
(Thinking of Change)
Preparation/
Determination
(Ready for change)
Stage during which a person
does not even consider the need
to change:
• Have not had sufficient
experience with negative
consequences
• Tipped toward negatives of
change
In this stage, a person considers
changing a specific behaviour:
• Beginning to seek relevant
information
• Re-evaluating behaviour
• Obtaining help of others to
support future attempts
• Still weighing up options
• Not ready to take action
The stage where a person
makes a serious commitment to
change
• Ready to take action in the
next 30 days
• Need to set goals and
develop priorities in order to
manage illness
• Reflective listening
• Empathy
• Effective questioning
• Provide objective
information in a
non-judgmental manner
• Explore barriers
(Action-oriented messages are
not appropriate)
• Reflective listening
• Empathy
• Effective questioning
• Provide non-judgmental
objective information that
may be taken away
• Encourage the patient to
accept ownership of the
problem
• Increase awareness of
negative questions
• Recognise how situations
effect illness
• Encouragement
• Empathy
• Goal setting
• Support of self-efficacious
behaviour
Stage Explanation of Stage Approach Suitable to Stage
Stages of Change and approaches that are most appropriate ateach stage
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Action
(Changing Behaviour)
Maintenance
(Maintaining change)
Change begins (this can be
large or small changes)
• Efforts made to modify
habits and environment
• Increased use of behavioural
processes of change (eg
restructuring one’s
environment, removing
alcohol)
Change is sustained over a
period of time
• Substituting alternatives for
problem behaviours eg
relaxation
• Taking responsibility for
actions
• Susceptible to relapse. Need
to remain aware of stimuli
that may trigger problem
behaviours
• Encourage stimulus control
• Skills training interventions
• Encourage support from
others
• Do not view relapse as
failure, but as a way to gain
knowledge of triggers
• Decrease environmental and
internal stimuli that trigger
problem behaviours
Stage Explanation of Stage Approach Suitable to Stage
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Principles for effective management
1. Patient-centred approach
The promotion of chronic condition self-management requires a patient-centred approach,
as the core principle involves the patient contributing to and driving the process. A disease-
centred approach assumes the disease to be fully accounted for by deviations from the norm
of measurable biological variables. This approach is limited as it does not take into account
the whole person, and therefore will only allow partial enlistment of the patient in the
process (Stewart et al 1995). The patient-centred approach uses a biopsychosocial approach
to the provision of primary care and underpins self-management.
There are six interactive components involved with a patient-centred approach.
1. Exploring both the condition and the illness experience including:
• Their feelings, such as fear about being ill
• Their ideas about what is wrong with them
• The functional impact of their problems
• Their expectations about what should be done
2. Understanding the whole person. Over time the GP will come to know the patient.
3. Finding common ground. To develop an effective management plan, the patient
and GP must come to an agreement in three areas:
• The nature of the problems and priorities
• The goals of treatment
• The part of the GP, the patient and other health care providers
4. Incorporating prevention and health promotion. Finding common ground for
opportunities for disease prevention and health promotion.
5. Enhancing the patient-doctor relationship. The long-term nature of the
GP/patient relationship is essential.
6. Being realistic. While recognising that GPs have competing demands on their time,
the skills of priority setting, resource allocation and teamwork can be used to improve
efficient time management. It is also important to make goals and timeframes for
their achievement realistic.
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2. Decision-making
Patients are consumers who have a right to make informed decisions about their health
care.This is facilitated when the patient and the GP form a partnership.14 Health care choices
should be based on:
• GP’s clinical skills
• Best evidence from literature
• Preferences based on the chance of benefits and harm.
The GP and the patient can work together to determine an appropriate course of action and
solve problems that arise within the management plan by:
• Understanding the problem and goals clearly, considering a wide variety of courses of
action
• Creating multiple solutions to the problem
• Collecting all available information to use in a combined solution
• Weighing the pros and cons of each solution to determine depth of commitment to
each
3. Motivational Interactions
There are eight interaction technique strategies that can be used to motivate patients to
change or adopt healthful lifestyles (Compton et al 1999):
• Giving Advice
• Removing Barriers
• Providing Choice
• Decreasing Desirability
• Practising Empathy
• Providing Feedback
• Clarifying Goals
• Active Helping
Although motivational interviewing may be seen as a time consuming activity that does not
fit easily within the confines of the regular consultation, the effect that a GP can have on a
patient with even a brief encounter should not be overlooked. Motivation can be built upon
over time and within the development of the therapeutic relationship.
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Ev
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nceSection 8 - Level and Strength of Evidence
Where given, the level of evidence is based on the following criteria 16 :
Level Explanation
I Evidence obtained from a systematic review of all relevant randomised
controlled trials.
II Evidence obtained from at least one properly-designed randomised
controlled trial.
III Evidence obtained from any of the following:
• Well-designed pseudo randomised controlled trials (alternate allocation or
some other method).
• Comparative studies with concurrent controls and allocation not
randomised (cohort studies), case controlled studies or interrupted time
series with a control group.
• Comparative studies with historical control, two or more single arm studies
or interrupted time series without a parallel control group.
IV Evidence obtained from case series, either post-test or pre-test and post-test.
V Opinions of respected authorities, based on clinical experience, descriptive
studies or reports of expert committees
No After thorough searching, no evidence was found regarding recommendations
evidence in general practice for the target disease or condition.
Where given, the strength of evidence is based on the following criteria:
A: The recommendation is supported by scientific evidence from properly designed and
implemented controlled trials providing statistical results that consistently support the
guideline statement.
B: The recommendation is supported by scientific evidence from properly designed and
implemented clinical series that support the guideline statement.
C: The recommendation is supported by expert opinion.
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Section 9 - References
Cassidy CA (1999) Using the Transtheoretical Model to Facilitate Behaviour Change in Patients with Chronic Illness.
Journal of American Academic Nurse Practice 11: 281.
Compton P, Monahan G, Simmons-Cody H (1999) Motivational interviewing: an effective brief intervention for
alcohol and drug abuse clients. The Nurse Practitioner November 1999: 27–49.
Fisher L & Weihs KL (2000) Can addressing family relationships improve outcomes in chronic disease? The Journal
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Contacts / Resources
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Contacts / Resources
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The Royal Australian College of
General Practitioners
Developed by the Royal Australian College of General Practitioners
Funded by Commonwealth Department of Health and Ageing
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